www.aana.com/aanajournalonline AANA Journal April 2014 Vol. 82, No.

2 101
Some providers advocate using laryngeal mask air-
ways (LMAs) for procedures performed in the prone
position to meet the demands of quicker operating
room turnover time requirements, staffing reductions
and the desire to expedite patient recovery in the
postoperative period. We provide an update to a 2010
systemic review examining the use of LMAs in patients
in the prone position.
Six peer-reviewed articles described the use of
LMAs in prone patients: a randomized controlled
trial, 2 description studies, a case series, and 2 case
reports. The risk of publication bias was possibly
high. This evidence, mostly from lower level sources,
supports the use of the LMA in this setting, with risks
comparable to when LMAs are used in patients in the
supine position. Experienced providers should care-
fully select patients and procedures when considering
using LMAs for patients in the prone position. There
must be a plan to control the airway if problems are
encountered with the LMA. These devices might be
considered as a bridge device when a prone patient
is accidentally extubated. Additional rigorous studies
are needed before use of LMAs in this manner can be
widely recommended.
Keywords: Adult, laryngeal mask airway, LMA, prone.
An Update: Use of Laryngeal Mask Airway
Devices in Patients in the Prone Position
William Whitacre, CRNA, DNAP
Loraine Dieckmann, PhD
Paul N. Austin, CRNA, PhD
T
here are many types of laryngeal mask airway
devices (collectively referred to as LMAs), and
their use has become popular over the last 30
years. Since their introduction in the United
Kingdom in 1988 and subsequent use world-
wide, the use of LMAs has rivaled that of the endotracheal
(ET) tube as a method of securing the airway.
1,2
The LMA
is suggested to be safe and effective during spontaneous
and intermittent positive pressure ventilation for certain
patients receiving general anesthesia.
2
The device is also
used in cases in which it previously was considered con-
traindicated, including those with the patient in the prone
position.
3
The reluctance of providers to use the LMA in
this manner may in part be due to the view that these
devices are best used with patients receiving general anes-
thesia who can be managed with a face mask.
2
The authors of a 2010 systematic review
4
examined
the evidence for using LMAs for airway rescue in subjects
in the prone position. They concluded that elective use of
LMAs in subjects positioned prone is feasible. However,
they found that evidence was lacking supporting the use
of these devices for airway rescue in patients in the prone
position.
This update reviews the findings of this systematic
review
4
and examines subsequently published evidence
regarding the use of LMAs in patients positioned prone.
History and Review of the Literature
The process of positioning a patient prone requires extra
staff, careful positioning, and padding of the patient to
prevent injuries. There is also the risk of hypotension,
displacement of the ET tube, and impairment of ventila-
tion.
5,6
To reposition a patient whose ET tube was placed
while the patient was supine is physically demanding of
the staff and time-consuming, may delay operating room
turnover, and may prolong the stay in the postanesthe-
sia care unit. If the patient positioned himself or herself
prone before induction of general anesthesia and place-
ment of the LMA (Figure), this would alleviate many of
these concerns.
6
Figure. Method of Inserting a Laryngeal Mask Airway
When the Patient Is Prone
Note: Patients head is on a pillow and a pillow is placed
transversely under thorax. While extending the neck using
pressure on the forehead can be effective, often upward pressure
on the head while slightly extending the neck will facilitate mouth
opening.
6
The mouth can also be scissored open using the fingers
of the hand not holding the laryngeal mask airway. All parts of the
patients body must be carefully padded.
102 AANA Journal April 2014 Vol. 82, No. 2 www.aana.com/aanajournalonline
If a patient is unintentionally extubated while in the
prone position, reintubation is difficult. Although it
is possible to intubate the trachea while the patient is
prone, this intubation usually requires the patient to be
positioned supine.
7
Use of the LMA can provide a bridge
until the patient can be repositioned and intubated or can
aid reintubation while the patient remains prone.
8
The previously published systematic review
4
(Table 1)
analyzed 12 studies or reports but contained no random-
ized controlled trials (RCTs). The investigators of these
12 studies or reports examined the use of the following
devices in subjects positioned prone: LMA Classic, used
in 47% of subjects; LMA ProSeal, used in 52.8% of sub-
jects; and LMA Fastrach ET Tube (intubating LMA, or
ILMA), used in less than 1% of subjects. All these devices
are distributed by LMA North America Inc (now part of
Teleflex). The outcomes examined were successful place-
ment and ventilation. Complications related to insertion
were also summarized. The authors described the use of
a comprehensive search strategy and appraisal method.
Excluding control subjects, the LMA was placed in
466 subjects positioned prone.
4
In all but 3 of these cases
the LMA was inserted electively. In the remaining 3 cases
the LMA was placed after the patient was unintention-
ally extubated. Insertion of the LMA was successful in
all cases, with a first-attempt insertion rate of 87.5% to
100%. Ventilation was adequately maintained in 83.3%
to 100% of the subjects. Hypoventilation was successfully
managed by instituting positive pressure ventilation or
reinsertion of the device with the subject remaining in
the prone position. Complications included LMA malpo-
sition requiring repositioning (0.4%-12.5% of subjects),
hypoventilation (0.9%-16.6% of subjects), laryngospasm
(1.3% of subjects), partial obstruction of the airway
(1.2% of subjects), bleeding (1.6%-2.7% of subjects),
bradycardia (0.9%-6.8% of subjects), and sore throat
(8.2%-20% of subjects). The authors concluded that this
technique is feasible in the elective setting but that there
was a lack of evidence for placing an LMA to manage the
airway in a patient who has been unintentionally extu-
bated in the prone position.
4
Materials and Methods
The PICO Question. A PICO (patient or population,
intervention, comparison, and outcome) question
9,10

guided the search for evidence for this update. The PICO
question was as follows: In adults with ASA physical
status 1 to 3, body mass index less than 35 kg/m
2
, and
no history of difficult intubation or ventilation who are
having anesthesia for surgical procedures in the prone
position, is the use of the various LMAs in the prone
position a safe practice? The outcome safe practice
centered on respiratory-related events.
Search Strategy. The search for evidence (2010-
2013) included the following online sources and search
engines: The Cochrane Database, PubMED, SUMSearch,
and Google Scholar. The following sources were included:
systematic reviews with or without meta-analysis, human
interventional and observational clinical trials, case
reports, and clinical practice guidelines not included in
the systematic review.
4
Low-level evidence was included
because of a suspected paucity of high-quality evidence.
The inclusion/exclusion criteria included full-text,
English-language articles or clinical practice guidelines
published in peer-reviewed journals or on the websites
of specialty organizations. The query was performed
using the keywords (used alone and in combination):
prone, laryngeal mask airway, outpatient, and surgeries.
Evidence sources involving LMA use in positions other
than prone were excluded. The evidence was appraised
and leveled according to the method proposed by Melnyk
and Fineout-Overholt.
11
Table 1. Summary of a Systematic Review
4
Describing Use of Laryngeal Mask Airways for Airway Rescue in
Patients in the Prone Position
Abbreviations: ET, endotracheal; LMA, laryngeal mask airway.
a
A total of 466 LMA insertions with subject prone and 60 control subjects in which the LMA was placed with the subject supine.
b
One group reported successful ventilation at 83.3% because of rotation of exible LMA during an endoscopic retrograde
cholangiopancreatography procedure. All reports less than 100% successful ventilation indicated that the problem was remedied by
positive pressure ventilation or repositioning of the LMA.
Evidence sources Evidence sources
examining elective examining LMA
use of LMA in Total for airway rescue Successful Successful
Types prone position No. of of patients in Type of insertion ventilation
of evidence (subjects) subjects prone position LMA rate (%) rate (%)
1 prospective 9 526
a
3 case reports LMA Classic First attempt: 83.3-100
b

cohort study, 1 describing 3 separate (n = 279) 87.5-100
noncontrolled patients LMA ProSeal Second attempt:
cohort study, 4 (n = 246) 100
retrospective LMA Fastrach
studies, 6 case ET Tube (n = 1)
studies
www.aana.com/aanajournalonline AANA Journal April 2014 Vol. 82, No. 2 103
Results
Appraisal of the Evidence. The search resulted in 51
potential evidence sources with 6 sources
12-17
involving
441 subjects meeting the inclusion criteria. The evidence
consisted of an RCT,
14
2 descriptive studies,
12,13
a case
series,
17
and 2 case studies
15,16
(Table 2). None of these
sources
12-17
appeared to share subjects, and the LMA was
placed with the subject in the prone position in all cases.
All evidence was from investigators practicing outside the
United States.
The RCT
14
compared the use of the LMA ProSeal
and the LMA Supreme (LMA North America Inc) in
subjects in the prone position for general surgery. The
sample was 120 subjects undergoing various procedures,
including pilonidal cyst excision, melanoma excision, or
microdiskectomy, and was calculated using the results
from a previous study.
13
This sample size was required
to detect a 12% incidence of the need for manipulation
of the LMA Supreme for optimal placement to provide ef-
fective ventilation in the prone position ( = .05, = 0.2).
There were no significant differences between groups
in age, gender, body mass index, and type and duration
of surgery. Subjects were blinded to the type of LMA.
Postoperative observations were recorded by blinded
observers, with intraoperative observations recorded
by nonblinded observers. The subjects in this RCT ac-
counted for about 30% of all subjects in the evidence
12-17

appraised for this update.
The authors of 2 prospective descriptive studies
12,13

examined the use of the LMA Supreme in subjects in
the prone position. The first study
12
evaluated the LMA
Supreme in 205 subjects undergoing spinal surgery.
This accounted for nearly 50% of all subjects in the evi-
dence
12-17
appraised for this update. The second study
13

evaluated the LMA Supreme in 40 subjects undergoing
pilonidal sinus or melanoma excision, bone marrow
aspiration, or diskectomy. Neither of these studies
12,13

mentioned a method for determining sample size. These
studies used convenience samples meeting their inclu-
sion criteria. The LMA Supreme devices were inserted by
both trainees
12
and experienced practitioners.
12,13
There
was no blinding. One of the authors (C. Verghese)
12

reportedly received an annual honorarium from the
LMA company, and an author from the other study (J.
Brimacombe)
13
worked as a consultant for the same
company. The LMAs were supplied free of charge by a
distributor for one investigation.
13
The case series
17
was reported as a letter to a journal.
The authors described the use of the LMA Supreme in
74 subjects undergoing liposculpting surgery. There was
no mention of the method of sample size determination,
and there was no blinding. The level of experience of the
providers was not indicated. Outcomes reported included
successful placement, successful ventilation, regurgita-
tion, and sore throat.
One case report
16
described the use of the ILMA for
a patient in the prone position who was stabbed in the
lower back, with the knife remaining in the patient.
Anesthesia was induced with the patient in the prone
position; an ILMA was placed for ventilation, and the
intubation was accomplished via the ILMA. Another case
report
15
described a dislodgment of a decayed premolar
associated with the insertion of the LMA in a patient with
inadequate epidural anesthesia undergoing hemorrhoid-
ectomy in the prone position.
Successful Placement of the Laryngeal Mask Airway.
The results of the evidence
12-17
are summarized in Table 3.
The ndings of the RCT
14
indicated that the LMA ProSeal
and LMA Supreme were successfully placed in all subjects,
with the rst-attempt success ranging from 98% to 100%.
There was no signicant difference in the mean time to
place either device, ranging between 16 and 17 seconds.
A LMA Supreme was successfully placed in all sub-
jects in the descriptive studies
12,13
and the case series.
17

It was placed successfully on the first attempt in 82.5%
13

to 93.2%
17
of subjects. The LMA was also successfully
placed in both case reports
15,16
but required 3 attempts
in 1 subject.
15

Successful Ventilation. In the RCT,
14
successful
ventilation was attained in all subjects with the LMA
ProSeal and LMA Supreme. Optimal ventilation was at-
tained in 58 of 60 subjects in the LMA ProSeal group and
51 of 60 subjects in the LMA Supreme group (P < .05).
Nonoptimal ventilation was defined as an air leak or
abnormal airway pressure requiring interventions such
as adjustment of the insertion depth, cuff volume, and/
or head-neck position. Mean seal pressure was slightly
higher with the LMA ProSeal compared with the LMA
Supreme (31 cm H
2
O compared with 27 cm H
2
O).
Positive pressure ventilation was maintained in all
patients in both descriptive studies,
12,13
with an air leak
or high airway pressures in 5 of 40 subjects in the second
study.
13
Positive pressure ventilation was also delivered
successfully in all subjects in the case series
17
and the 2
case studies.
15,16

Complications. None of the authors
12-17
described
having to turn the subject supine to manage the airway. No
problems were reported with face-mask ventilation. The
authors of the RCT
14
described a single subject requiring
2-handed ventilation. Laryngospasm occurred in 7 subjects
in the RCT
14
and in 1 subject in one of the descriptive
studies.
12
All occurrences were successfully treated in each
case by deepening the anesthetic level or administering a
neuromuscular blocker. Regurgitation via the drain tube of
the LMA occurred in a subject in the RCT
14
and a subject in
a descriptive study
12
with no evidence of aspiration. Blood
was noted on the LMA in 9 of 120 subjects in the RCT
14

and 3 of 40 subjects in a descriptive study.
13
The incidence
of sore throat was 4.2% in the RCT,
14
7.5% in a descriptive
study,
13
and 1.4% in the case series.
17
104 AANA Journal April 2014 Vol. 82, No. 2 www.aana.com/aanajournalonline
Study
Evidence
type and
level
a
No. of
subjects
BMI
(kg/m
2
)
Surgery
types
Mean
duration
of
surgery
(min)
Type of
LMA
Inserter
and No. of
subjects
(%)
Outcome
measures
Sharma et al,
12

2010
Descriptive
study
Level VI
205 Median,
27-28
(IQR
25-31)
Microdiskectomy,
multiple-level spinal
decompression,
spinal fusion
102
(SD 150-
300)
LMA
Supreme
Experienced
provider: 163
(79.5)
Trainee: 42
(20.5)
Successful
placement;
regurgitation;
complications
Lpez et al,
13

2010
Descriptive
study
Level VI
40 Mean,
24-25
(SD 4)
Pilonidal sinus
excision;
melanoma
excision; bone
marrow aspiration;
diskectomy
36-132
(SD 12-78)
LMA
Supreme
Experienced
provider: 40
(100)
Ease of insertion;
No. of attempts;
time to insert;
efficacy of
ventilation; airway
seal pressure; mean
airway pressure;
gastric tube
insertion; fiberoptic
view of vocal cords;
blood staining on
LMA Supreme; sore
throat
Lpez et al,
14

2011
Randomized
controlled
trial
Level II
120 Mean,
25-26
(SD 3-4)
Pilonidal cyst
excision; lumbar
microdiskectomy;
melanoma
excision; varicose
vein excision; bone
marrow aspiration;
Achilles tendon
repair; liposuction;
gluteus tumor
excision
25-124
(SD 8-27)
LMA
Supreme
LMA
ProSeal
Experienced
providers:
120 (100)
Successful insertion;
ease of insertion;
initial quality of
ventilation; gastric
access; fiberoptic
bronchoscope
manipulation;
fiberoptic
bronchoscope view
of vocal cords;
laryngospasm;
leakage;
displacement;
hiccup; regurgitation;
visible blood on
LMA; dysphonia;
sore throat
Chau et al,
15

2011
Case study
Level VI
1 19.5 Hemorrhoidectomy NA LMA
Classic
NA Placement attempts;
dental injury
Samantaray,
16

2011
Case study
Level VI
1 NA Removal of knife
impaled in lower
back
NA LMA
Fastrach
ET Tube
NA Insertion success;
adequacy of
ventilation
Thomas et al,
17

2012
Case study
Level VI
74 NA Liposculpting NA LMA
Supreme
NA Successful
insertion; delivery
of intermittent
positive pressure
ventilation; peak
airway pressure;
regurgitation; sore
throat
Table 2. Summary of Additional Evidence Regarding Placement and Ventilation Using a Laryngeal Mask
Device in the Prone Position
Abbreviations: BMI, body mass index; ET, endotracheal; IQR, interquartile range; LMA, laryngeal mask airway device; NA, not available;
SD, standard deviation.
a
Evidence appraised and leveled using the method described by Melnyk and Fineout-Overholt,
11
ranging from level I evidence
encompassing systematic reviews to level VII evidence that includes expert opinion.
www.aana.com/aanajournalonline AANA Journal April 2014 Vol. 82, No. 2 105
Study
Evidence type/
No. of subjects/LMA type Outcomes
Sharma et
al,
12
2010
Descriptive study/205 subjects/
LMA Supreme
Successful placement
First attempt: 184 subjects (89.8%)
Second attempt: 19 subjects (9.2%)
> 2 attempts: 2 subjects (1%)
Successful maintenance of ventilation: 205 subjects (100%)
Regurgitation via drainage tube: 1 subject (0.5%)
Laryngospasm: 1 subject (0.5%); resolved with NMBA; no further problems
Lpez et al,
13

2010
Descriptive study/40 subjects/
LMA Supreme
Ease of insertions
First attempt, no additional maneuvers: 33 subjects (82.5%)
First attempt, additional maneuvers: 4 subjects (10%)
Second or third attempt: 3 subjects (7.5%)
Number of attempts
First attempt: 37 subjects (92.5%)
Second attempt: 3 subjects (7.5%)
Time to insert (s): 21 (SD 15)
Efficacy of ventilation
Normal ventilation without air leak: 35 subjects (87.5%)
Air leak or high airway pressures: 5 subjects (12.5%)
Airway seal pressure (cm H
2
O): 27 (SD 5)
Mean airway pressure (cm H
2
O): 17 (SD 3)
Gastric tube insertion
Easy: 39 subjects: (97.5%)
Maneuvers required: 1 subject (2.5%)
Blood staining on LMA Supreme
Mild: 3 subjects (7.5%)
Moderate: 0
Severe: 0
Sore throat 1 hour after surgery
Mild: 3 subjects (7.5%)
Moderate: 0 subjects
Severe: 0 subjects
Lpez et al,
14

2011
RCT/120 subjects/LMA
Supreme: 60 subjects; LMA
ProSeal: 60 subjects
No difference between devices in the following outcomes (combined data from LMA
Supreme and LMA ProSeal groups):
Successful insertion: 100% (rst time success: LMA ProSeal, 100%; LMA Supreme. 98%)
Time to insert (s): 16-17 (SD 5-6)
Ease of insertion
No resistance: 104 subjects (86.7%)
Maneuvers needed: 15 subjects (12.5%)
Reinsertion needed: 1 subject (0.8%)
Airway pressure (cm H
2
O): 16-18 (SD 3)
Complications
Laryngospasm: 7 subjects (5.8%)
Leakage, displacement: 5 subjects (4.2%)
Hiccup: 2 subjects (1.7%)
Regurgitation via drain tube of LMA 1 subject (0.8%)
Visible blood on LMA: 9 subjects (7.5%)
Dysphonia: 1 subject (0.8%)
Sore throat 1 hour after arrival in postanesthesia care unit: 5 subjects (4.3%)
There were differences (P < .05) in the following outcomes:
Initial quality of ventilation:
Optimal: LMA ProSeal, 58 subjects (97%); LMA Supreme, 51 subjects (85%)
Readjustment needed: LMA ProSeal, 2 subjects (3%); LMA Supreme, 9 subjects (15%)
Mean seal pressure (cm H
2
O):
LMA ProSeal, 31 (SD 4); LMA Supreme, 27 (SD 4)
Chau et al,
15

2011
Case study/1 subject LMA
Classic
Insertion success: 100%
Placement attempts: 3
Dental injury: Dislodged premolar; recovered when LMA removed
Samantaray,
16

2011
Case study/1 subject/LMA
Fastrach ET Tube
Insertion success: 100%
Adequacy of ventilation: 100%
Thomas et
al,
17
2012
Case series/74 subjects/LMA
Supreme
Successful insertion: 100%
First attempt: 69 subjects (93.2%)
Second attempt: 5 subjects (6.8%)
Successful delivery of intermittent positive pressure ventilation: 74 subjects (100%)
Mean peak airway pressure (cm H
2
O): 12-27
Regurgitation: 0
Sore throat 1 hour postoperatively: 1 subject (1.4%)
Table 3. Results of Evidence Regarding Placement and Ventilation Using a Laryngeal Mask Device in the Prone
Position
Abbreviations: ET, endotracheal; IQR, interquartile range; LMA, laryngeal mask airway; NMBA, neuromuscular blocking agents; SD,
standard deviation.
106 AANA Journal April 2014 Vol. 82, No. 2 www.aana.com/aanajournalonline
Discussion
The rates of successful insertion, ventilation, and compli-
cations described in the current evidence were similar to
the rates reported by the authors of the previous systematic
review.
4
The most notable difference between the system-
atic review and this update is the type of LMA examined
by the study investigators. In the current update, about
94% of the subjects were managed with an LMA Supreme;
about 5%, with an LMA ProSeal; and less than 1%, with
an LMA Classic. In the systematic review slightly less than
50% of the subjects had a LMA Classic placed while they
were in the prone position, and slightly more than 50%
had an LMA ProSeal placed while prone. Just one case
report mentioned placing an ILMA in a prone patient. In
addition, no RCTs were included in the systematic review,
4

whereas 1 RCT
14
was located for this update.
Because of the heterogeneity of the study methods,
the results of the evidence sources are reported and a
meta-analysis was not done. Examples of this heteroge-
neity include that the definition of laryngospasm was not
consistently supplied across the evidence sources.
12,14
In
addition, the authors of one study
13
defined a decrease
in oxygenation as an oxygen saturation measured by
pulse oximetry (SpO
2
) of less than 90%, whereas others
14
defined this as less than 95%.
With only one higher level source located,
14
the evi-
dence used in this update must be cautiously considered.
The LMA Supreme was used in 95% of the subjects.
12-17

The outcomes reported when using this device
12-14,17

suggested that use of the LMA Supreme in patients un-
dergoing procedures in the prone position was feasible.
The incidence of successful insertion, ventilation, and
complications was not markedly different across this evi-
dence.
12-14,17
These outcomes were also similar to those
reported in the 2012 review
18
of the LMA Supreme, which
included 19 studies (12 RCTs and 7 single-device pro-
spective studies) totaling approximately 1,524 subjects.
In that study, 84% of the subjects had the LMA Supreme
placed while they were in the supine position. These
authors reported that the insertion success rate, insertion
time, and complications were comparable when using the
LMA Supreme or the LMA ProSeal, but a higher oropha-
ryngeal leak pressure was observed with the LMA ProSeal.
The results of the single RCT
14
are noteworthy because
this source provides a higher level of evidence compared
with the other sources reviewed for this update. This
RCT
14
compared use of the LMA Supreme and the LMA
ProSeal in subjects positioned prone. The investigators
concluded that management of subjects in the prone po-
sition was effective using both devices but that the LMA
ProSeal attained a higher seal pressure and required fewer
adjustments to attain optimal ventilation. A modified
technique was used to place the LMA ProSeal, in which a
suction catheter was first placed through the drain tube
and extended beyond the distal end. The suction catheter
entered the esophagus first and allowed it to guide the
tip of the LMA ProSeal. The performance of the LMA
ProSeal was similar to that reported in the earlier system-
atic review
4
and to when it was used with patients in the
supine position.
19

The ILMA
16
and the LMA Classic
15
were used success-
fully in each case study, and the outcomes were compa-
rable to the results of the prior systematic review.
4
The
small number of LMA Classic devices seen in the current
evidence compared with the prior systematic review
probably is due to the current availability of the LMA
ProSeal and LMA Supreme. These devices offer advan-
tages over the LMA Classic, including the presence of a
drain tube and a posterior cuff on the LMA ProSeal,
19
and
the design of the ILMA facilitates endotracheal intubation
while ventilating the patient using the device. Placement
of the LMA Classic in a patient in the prone position may
have contributed to the avulsion of a decayed premolar in
a patient with very poor oral health.
15
The case report
16

described the use of the ILMA to successfully ventilate
and intubate a patient who had a large knife protruding
from his lower back. A similar use was also reported in a
case study included in the prior systematic review.
4
These
case reports may be subject to higher levels of publication
bias compared with higher level evidence, and the results
must be cautiously considered.
Clinicians must carefully consider this evidence when
contemplating managing the patients airway in the prone
position. An important advantage of placing the LMA
while the patient is prone is the time saved positioning
the patient. This has implications for ambulatory surgery
settings, where cases may be short and turnover time
between cases must be optimized for efficiency. Although
LMAs were successfully used in patients undergoing pro-
cedures up to 5 hours,
12
this practice must be carefully
considered, because the time savings in case turnover is
diminished with long cases. Additionally, there is little
evidence to support the safety of this practice. Successful
LMA use with prone, obese subjects was also reported
in the same descriptive study,
12
with about 40% of the
subjects having a body mass index of 30 kg/m
2
or higher.
Providers must very carefully consider all risks, benefits,
and options before managing the airway of an obese
patient in the prone position with an LMA.
Summary
Both the results of the previously published systematic
review
4
and the current evidence
12-17
suggest that using
an LMA with a prone patient may be an acceptable al-
ternative to endotracheal intubation for select patients.
The reduced requirement of extra staff for positioning,
5

reduction in induction to incision time,
5
successful
placement and ventilation,
4,12-17
and low rate of compli-
cations
4,12-17
support considering using the LMA in the
prone patient. The LMA ProSeal may offer advantages
www.aana.com/aanajournalonline AANA Journal April 2014 Vol. 82, No. 2 107
over other types of LMAs,
14
and the drain tube built into
the LMA Supreme may offer advantages over the LMA
Classic.
12,13,17
Clinicians practicing in the United States may be
hesitant to adopt practices described by authors practic-
ing abroad and may view use of an LMA to be safe in
those patients who can be managed using a face mask.
2

Clinicians should consider a number of factors if con-
templating using an LMA in this manner. Only providers
experienced with LMAs should consider using an LMA
with a prone patient.
13
It seems prudent to have skilled
assistance available. A plan must be in place to immedi-
ately turn the patient supine if problems are encountered
during insertion. A plan must also be discussed with the
operative team to reposition the patient intraoperatively
in case it is necessary to use other means to manage the
airway. Patients should be carefully selected for prone
LMA use. Patients should not be obese, should have
normal airway anatomy, and should be at minimal risk
for aspiration. Finally, this practice should be considered
only for short procedures.
There is a distinct possibility that the complication
rate is higher when using the LMA in patients positioned
prone but that providers are not reporting these complica-
tions. There may be publication bias in favor of publish-
ing the successful use of the device in patients positioned
prone. Future high-quality multicenter RCTs should
be conducted before this practice can be widely recom-
mended. These studies should examine the outcomes of
subjects undergoing surgery in the prone position when
managed with an LMA compared with an ET tube.
Using an LMA as a bridge for a patient unintentionally
extubated in the prone position seems reasonable, but
the provider must have a backup plan in case of failure.
Because of the rare nature of the problem, it is doubtful
there will be RCTs conducted examining this practice.
Transfer of knowledge gained from elective placement
of LMAs in prone patients may be problematic because
of the difference in conditions between emergency and
elective situations.
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AUTHORS
William Whitacre, CRNA, DNAP, is a staff nurse anesthetist with Anes-
thesia Associates Northwest servicing Providence Milwaukie Hospital and
Mt. Scott Surgical Center in Portland, Oregon. The author was a student
in the Doctorate of Nurse Anesthesia Practice Program at Texas Wesleyan
University in Fort Worth, Texas, at the time this article was written.
Loraine Dieckmann, PhD, is an associate professor of pharmacology in
the Graduate Programs of Nurse Anesthesia at Texas Wesleyan University.
Paul N. Austin, CRNA, PhD, is a professor, Doctorate of Nurse Anes-
thesia Practice Program at Texas Wesleyan University.
ACKNOWLEDGMENT
The authors would like to thank Howard Wilpon, MD, and Lotika Sharma,
CRNA, MSN, for their assistance with the Figure.